Dec. 11, 2018
Metastatic lesion involving the thoracic cavity, ribs, spine and epidural space
A and B. Sagittal and axial T2 MRIs show a large metastatic lesion involving the thoracic cavity, ribs, spine and epidural space in a 67-year-old man with metastatic renal cell carcinoma. The patient experienced intractable back and thoracic radicular pain. After a preoperative embolization procedure to reduce the blood supply to the tumor, Mayo Clinic neurosurgeons worked with colleagues in cardiothoracic surgery to maximally debulk the tumor and stabilize the spine with T5-11 instrumentation. C and D. Postoperative anteroposterior and lateral X-rays show the surgical results. The patient has remained ambulatory, and his preoperative pain symptoms have improved. He continues to receive adjuvant treatments.
Mayo Clinic has the multidisciplinary, subspecialized expertise to manage care for people with even the most complex intradural and vertebral tumors, including both primary and metastatic disease. Depending on the type of tumor, treatment at Mayo might involve multidisciplinary en bloc resection, minimally invasive surgery, separation of the tumor from the spinal cord or proton beam therapy. These approaches are available at all three Mayo Clinic campuses.
"Spinal oncology problems can be very complicated and truly require a multidisciplinary team. When a patient comes to Mayo Clinic, his or her case is evaluated by a team that includes a neurological radiologist, medical oncologist, radiation oncologist and spinal surgeon. Other specialists are involved as needed. We then discuss our recommendations with the patient and tailor a unique treatment plan for that individual," says Matthew T. Neal, M.D., a neurosurgeon at Mayo Clinic in Phoenix/Scottsdale, Arizona.
Spinal tumors are often aggressive and debilitating, causing significant pain and rapid development of neurological problems. Patients can progress to paraparesis, which typically affects bowel and bladder function and increases the risk of decubitus ulcers, deep vein thrombosis and pneumonia.
"These patients have tremendous quality-of-life issues. We have a group of surgeons with the expertise to treat these tumors aggressively when appropriate," says Maziyar A. Kalani, M.D., a neurosurgeon at Mayo Clinic's campus in Arizona.
Mayo Clinic's expertise in spinal oncology encompasses all types of spinal tumors. If a tumor-related syndrome is suspected, geneticists are part of the treatment team. Mayo Clinic has a Neurofibromatosis Clinic and a von Hippel-Lindau Clinic with the range of specialists needed to manage patients with these syndromes.
Mayo Clinic also has neurosurgeons who subspecialize in spinal surgery. "Some types of spinal tumors are encountered very infrequently. Subspecialized training in spinal surgery is a very big advantage in treatment of these complex spinal cases," says Jamal McClendon Jr., M.D., a neurosurgeon at Mayo's campus in Arizona.
At Mayo, a multidisciplinary care team considers surgical and nonsurgical options for each patient, based on the type and location of the spinal tumor. "In some cases, when we know that radiation treatment is not very effective, we may be more aggressive resecting a tumor. We routinely use image-guidance technology, which can help maximize tumor removal and can increase safety when hardware is being implanted," Dr. Neal says. "In other cases, the tumors are very effectively treated nonsurgically."
Minimally invasive surgical techniques are often used in spinal oncology procedures when possible. "Limiting the incision sizes can expedite the patient's recovery," Dr. Neal says.
Dr. Kalani notes that separation surgery can be particularly beneficial in patients with metastatic disease. "For patients who have a controlled disease state and one or two solitary metastases to the spine, separation surgery can significantly improve the long-term neurological and biomechanical outcomes," he says. "Spinal metastatic disease is one of the few fields in neurosurgery where we have a high level of evidence that spinal decompression, stabilization and radiation can not only improve quality of life but also actually increase longevity."
Proton beam therapy is also a treatment option, particularly for tumors resistant to traditional radiotherapy. Proton beam therapy allows radiation delivery to conform more closely to the tumor.
"We are fortunate to have subspecialized expertise from our radiation and medical oncologists who help formulate the treatment plan, whether surgery is needed or not," Dr. Neal says.
After surgery and adjuvant therapy, physiatrists work with patients to optimize pain control and rehabilitation. Long-term follow-up care is available at all three Mayo Clinic campuses.
"With every patient, our goal is to provide not only compassionate care but the highest quality of care," Dr. Neal says.